ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

It’s 8pm on 11/2/17 (or 2/11/17 depending on your preference) and it’s currently a brisk 48oF (9oC) compared to 44oC at home yesterday.

My initial impression on arriving in Seattle was the apparent anti-Trump sentiment in the Pacific North-West evident from the graffiti on the wall on the way from the airport announcing “STOP TRUMP”, to the Washington state legal action against the travel ban, which is currently underway.

Day 1: Today I attended the 7th International Workshop on HIV and Women, a small workshop with a select audience of 120 registrants, 10% being men. The major focus of this meeting is to present the latest data on HIV as it affects women and most importantly to promote a dialogue and interaction between participants.

Session 1 focussed on current controversies in breastfeeding – related basic science, clinical trial evidence was presented and the session concluded with a debate on the pros and cons of breastfeeding in the context of HIV.

Infant feeding is a complex issue and related choices by an HIV infected mother should always support prevention of HIV transmission, provide greatest nutritional benefit and prevent the infant experiencing significant non-HIV morbidity and mortality eg from diarrhoeal diseases.

There are many factors which can influence transmission of HIV via breast milk which I will not elaborate here. Note that some studies have shown that mothers with undetectable HIV RNA in the blood can still transmit HIV in breast milk because antiretroviral drugs do not pass into breast milk with full, equal efficacy. Studies indicate passage of NNRTIs into breast milk of 80%, PIs 20%, and there is no passage of Integrase Inhibitors (in the one paper to date). Further sub-optimal drug levels of ARVs in breast milk may contribute to drug resistance in the infant. There is also a different viral load in breast milk between each breast. Recent trials (Mma Bana and PROMISE Study) indicated risk of MTCT from breast milk was 0.3% in the context of ARV treatment. However, we do not know what may be the best ARV regimen for breast feeding mothers.

It is very important to be aware of the latest WHO Guidelines which were updated on 01/08/2016. I draw your attention to these new guidelines as they do now have more relevance to developed world settings. The WHO Guidelines have usually been intended for countries with high HIV prevalence, and there is not wide adoption of the WHO Guidelines in highly developed countries, and of course there are longstanding regional guidelines in operation – eg US Guidelines (last updated October 2016) where breast feeding is not recommended (AII), with guidelines from other regions - BHIVA/CHIVA, Australia, Canada (CAPG and SOGC) being similar.

In a number of developed world settings, women are starting to breast feed in the context of full virological suppression and infant post exposure ARVs (including triple therapy!) and there are some emerging case reports on outcome. In many instances women are breast feeding without their health providers knowing.

Canada is now developing a national policy document relating to the follow-up of women who have breast fed their infants. Further, be aware that Switzerland is now starting to allow breast feeding for women with an undetectable HIV viral load and the identified cohort will be followed prospectively.

It is increasingly apparent that there is a now an emerging dilemma as to whether we can start to recommend breast feeding by mothers with HIV infection in all settings. Are we reaching a point now in our clinical practices, where there is sufficient safety data to consider supporting breast feeding? A recent survey of health care providers suggests that nearly 50% of health care providers would consider offering a breast-feeding option regardless of speciality. This is in the context of a background prevailing attitude of health providers which is, quite understandably, zero tolerance for any infant HIV acquisition. There was also acknowledgement that there is an evolving professional tension in some settings, between Paediatric ID clinicians and maternal HIV clinicians and a tendency for there to be “policing of mothers” in the community and by some health providers.

The outcome of the debate on these issues in this session, was that it is time for there to be a more open discussion between women living with HIV, in a “shared care” arrangement with their health provider, on the risks and benefits of breast feeding. This discussion must also emphasise maintaining adherence and full virological suppression, as studies have shown a decline in adherence in the post-partum period. The session also concluded that there needs to be a relevant dialogue between health care providers and the development of governmental or professional organisational guidelines to assist health care providers in offering a breast feeding option.

·In conclusion PrEP didn’t precipitate condom less sex as condom less sex predated PrEP but it does seem to be reinventing the idea of‘sexual citizenship’ (‘sexual citizenship’ first described by David T Evans in 1993 as the rights and responsibilities around ones sexual career). It seems a new stigma evolving with sexual rejection of condom users. This tension between PrEP and non-PrEP users needs to be addressed to develop the idea of that a combination of health promotions can reduce HIV.

·The Implication is that health promotion needs to be embedded in the conversation that communities have in order to be relevant.Future studies need to follow theses attitudes/ trends over time.

Need early Ca detection model:less than 2cm lesion possibly just excision with no spread or sphincter involvement,no chemo or radiation

Implement anal digital

Based on Wilson and Jungner screening critera

;"GIVING THE FINGER TO ANAL CANCER"his PhD title

Key findings ;all specialists think it is important to screen for anal Ca but arent doing it

www.anal.org.au/clinician MSHC;:

Annual DARE study and recommendations

Acceptable,minimal s/e

99% clients willing to have annual dare

Dare is cost effective,safe,acceptable

TIME TO Do DARE translating evidence into action

Summarised;

Screen for precursor lesions

Triage

RCT FOR DARE unlikely

Jason is running an educational session at the ASHM hub Friday

DO YOU DARE?

Timely as Tasmania Sexual Health are fortunate to have Prof Richard Turner:Colorectal surgeon Royal Hobat Hospital/UTAS

Continuing his research with monitoring HSIL anal paps :HRA ,histology ?treatment for HIV clients and Women with HSIL paps

He has spent time to demostrate DARE to all clinicians and advises annual DARE

The final session by Brad Atkins of his horror story of his diagnoses and treatment of anal cancer and being totally uninformed and underprepared and to be reminded of the STIGMA,embarrasment people feel

Makes it urgent to "AT LEAST LOOK AND PUT YOUR FINGER IN OR YOU WILL MISS IT"

Day 2 started off really well with a great presentation from Rebeca Guy, Associate Professor, The Kirby Institute, UNSW, Australia about using New Technology in STI clinics.....IT! Young people have access to IT 24/7

Basically, when someones at risk of an STI, they want an appointment ASAP so why not use electronic self registration and appointments, they can then use a computer assisted survey instrument (CASI) to input their sexual history = cuts down time, avoids awkward questions and more honest answers are given!

CASI can also be used for self collection of samples with Enrolled Nurse staffing = increase in clinic capacity, halves waiting time and process, therefore more clients seen!

In GP clinics there's a problem with low rate of Chlamydia testing in 15-29 years. Studies show that 73.4% of CT cases are asymptomatic and are attending the GP clinic for a non sexual health problem! Computer prompts could help and in a trial of 68 clinics using computer prompts there was a 30% increase in testing!

Having these computer prompts for STI screening can also be helpful in Aboriginal Adult health checks = 10% +ve STI's found using very little resources.

SMS reminders for treatment and recall in remote areas = quicker and higher numbers treated. Also SMS reminders for TORI /POC shows 64% of clients attending for recall but only 30% without SMS reminder.

Point of care technology gives results for CT/NG in 90 minutes, with high accuracy = quick treatment

Websites such as "Let them know" allow clients to notify partners by SMS, email, letter and has high usage, around 20,000 SMS's sent/year.

Online education can be used for parents and kids.

When a 2013 study asked secondary school age kids about reasons for not using condoms, one of the answers was "sex just happened and we didn't have a condom" But there's even an APP for condom delivery! Mind you it takes 1 hour and costs $15!!

Online resources for meeting people like Tinder would be a great opportunity to provide information on STI clinics, where to get tested, postal test kits etc

I'll definitely take back some of these ideas to Sexual Health Quarters in Perth (SHQ) especially CASI which would be so good to use in our extremely busy drop in STI clinics.

These women should be treated as for P.I.D. (important to rule out Bacterial Vaginosis at the same time)

Clinicians should consider the increasing evidence of Mycoplasma Genitalium (MG) resistance to Azithromycin and consider a 7 day course of twice daily Doxycycline 100mg po.

In my experience, Doxycycline is not very well tolerated in a large number of patients. Gastrointestinal side effects and problems with photosensitivity are some of the more common side effects. In remote settings, would clinicians rather treat with Azithromycin 1g po stat on day of consult, examination and testing?